Form Ca1 - Wihs Medical Record Abstraction
ADVERTISEMENT
1
2WIHS MEDICAL RECORD ABSTRACTION FORM
FORM CA1
HOSPITAL INFORMATION
FORM VERSION 02/01/96
WIHS
DATE OF HOSPITAL
ID NUMBER:
ADMISSION:
ABSTRACTOR'S INITIALS:
____ ____/____ ____/____ ____
|__| - |__|__| - |__|__|__|__| -|__|
|____|____|____|
M
D
Y
A1.
Date of abstraction
____ ____/____ ____/____ ____
M
D
Y
Participant’s date of birth
A2.
____ ____/____ ____/____ ____
M
D
Y
B. ADMISSION INFORMATION
B1.
Date of admission
____ ____/____ ____/____ ____
M
D
Y
B2.
Date of discharge
____ ____/____ ____/____ ____
M
D
Y
B3.
The Participant left Against Medical Advice (AMA)?
Yes .....................................................1
No .......................................................2
C. DISCHARGE INFORMATION
C1.
Disposition (Circle One)
Alive .............................. 1 (C3)
Dead ............................... 2
C2.
Death Information
C2a.
Date of death
____ ____/____ ____/____ ____
M
D
Y
YES
NO
C2b. Copy of death certificate obtained?
1 *
2
C2c.
Autopsy done?
1
2 (C2e)
WIHS Medical Record Abstraction Form CA1 -- Hospital Information -- Version 02/01/96 - Page 1 of 2
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Medical